Perceived health-related stigma among patients with breast cancer

Qin-Xin Wng,Yn Bi,Guo-Fng Lu,Ci-Yun Zhng

Department of Nursing,The First Hospital of Lanzhou University,Lanzhou,Gansu 730000,China

Perceived health-related stigma among patients with breast cancer

Qian-Xin Wanga,Yan Baia,Guo-Fang Lu,Cai-Yun Zhang*

Department of Nursing,The First Hospital of Lanzhou University,Lanzhou,Gansu 730000,China

A R T I C L E I N F O

Article history:

11 July 2017

Available online 10 November 2017

Stigma

Social stigma

Health-related stigma

Disease-related stigma

Breast cancer

Patients with breast cancer

Cancer

Breast cancer survivors face many challenges(particularly changes in body image)on their road to restoring physical and psychosocial health following diagnosis.Perceived health-related stigma(PHS)refers to the attachment of negative connotations to some types of disease diagnoses.PHS is common among patients with breast cancer and is associated with adverse emotions,attitudes and behaviors.This article summarizes the latest advances andnew perspectives on PHS of breast cancer patients and approaches to block this deleterious process.Effects of PHS on patients with breast cancer,in this paper,and measures,predictors and interventions of PHS have been discussed in depth.Future studies should continue to develop more effective instruments that are specialized for measuring PHS of breast cancer patients,explore the predictors of PHS,and discuss effective interventions on the basis of the predictors.©2017 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1.Introduction

Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer-related death in females worldwide,accountingfor23%ofallcasesofcancerand14%oftotalcancerdeaths.1Eachyear,alargenumberofwomenintheworldarediagnosedwith breast cancer,and the incidence of breast cancer has increased significantlyinthepastdecade,makingthiscanceracommonhealth problem among global women,particularly in rural areas.

Generally,breast cancer patients will be treated with surgery,chemotherapy,radiotherapy,or a combined treatment.2Nearly all patients who are diagnosed with breast cancer undergo surgical resection as an indispensable part of their cancer therapy.

Breast cancer patients can benefit from these treatments,but at the same time,they can also experience many deleterious effects.Many studies have shown that breast cancer diagnosis and treatment have considerable negative effects on the physical,psychological,and social health of patients and can reduce their quality of life.3-5Many patients with breast cancer suffer from physical and cognitive impairments,changes in body image and sexuality,fear of recurrences,economic stress,poor social support,role functioning constraints and familycrisis throughout the entiredisease process.6Disease-related stigma is common among patients with breast cancer.Whether patients receive mastectomy or breast conserving treatment,they feel stigmatized similarly.4The stigma of many diseases and disorders prevalent in the world has attracted increasing public health concern.Studies of breast cancer stigma found that stigma extensively exists in patients with breast cancer because of their physical and psychosocial stress.4,6-13

2.Perceived health-related stigma

The modern understanding of disease-related stigma owes much to sociologist Goffman,14who defined stigma as an attribute that links an individual to an undesirable stereotype.Goffman argued that the stigmatized person is reduced in other people's minds from a whole and ordinary person to a disgraced or discounted one.Stigma regarding disease can take on many different forms,which include discriminatory behavior from others,15,16delays in diagnosis or treatment,16,17reduced availability of healthcare services and limited research funding.18

Because stigma is a rather broad topic,it is important to acknowledge the distinctive features of perceived health-related stigma(PHS)and the social burden of illness.The current research focuses on PHS,which was defined as a social process or personal experience characterized by the perception of exclusion,rejection,blame or devaluation that results from experience oranticipation of an adverse social judgment about a group or person.19This judgment is based on an enduring characteristic of identity conferred by a particular health problem or health-related condition.20Stigmatization includes negative emotions and attitudes(e.g.,irritation,depression)as well as social avoidance of affected individuals.21PHS,which contributes to physical,psychological and social morbidity,has been identified as a barrier to health promotion.22

PHS has been extensively studied in illnesses that were poorly understood or defined,lacked effective treatment,and readily invoked fear within a population,such as mentalillness,HIV/AIDS,epilepsy and physical disability.16In recent years,cancer-related stigma has attracted increasingly more attention of researchers because public perceptions of cancer are often appraised more negatively than other serious diseases.Cancer and its treatment mayleave visible physical marks,such as alopecia or scars,and may simultaneously generate invisible marks,such as PHS.12,23Researchers have suggested that cancer stigma may be driven by fear of the illness itself and fear of death.21

3.PHS among patients with breast cancer

Compared with studies of stigma of other diseases,the studies of PHS of breast cancer started comparatively late.Although the quantity of relevant studies is limited,there is a rising trend in the number of studies year by year.The PHS of breast cancer is receiving increasingly more concern.This is as a result of the enormous negative impact PHS usually has on the patients and their families,and this impact could be felt at home,in the community and at the workplace.Breast cancer survivors face many challenges(particularly changes in body image)on their road to restoring physical and psychosocial health following diagnosis.According to studies of breast cancer stigma,PHS is common among patients with breast cancer and is associated with adverse emotions,attitudes and behaviors(such as depressive emotion,negative attitude and decreased healthcare seeking behavior).4,6-13

4.Measures of PHS of breast cancer

4.1.Social Impact Scale(SIS)

To measurethe PHS of patients with HIV/AIDS orcancer,File and Wright developed the SIS in 2000.24This 24-item scale includes four dimensions of PHS:social rejection(9 items,e.g.,“I feel others avoid me because of my illness”),financialinsecurity(3 items,e.g.,“My job security has been affected by my illness”),internalized shame(5 items,e.g.,“I feel I need to keep my illness a secret”),and socialisolation(7 items,e.g.,“I feel set apart from others who are well”).The total scale demonstrates good internal consistency reliability(Cronbach'sa=0.95),as do the subscales(Cronbach's a≥0.81).The SIS has been extensively used in studies of PHS of patients with HIV/AIDS or cancer.Whether this scale is suitable for the measurement of PHS of breast cancer patients depends on further examination.

4.2.Cancer Stigma Scale(CASS)

Marlow and Wardle provided the Cancer Stigma Scale(CASS),which can be used in the general population.25The CASS is a 25-item scale and made up of six subscales,which are Awkwardness(5 items),Severity(5 items),Avoidance(5 items),Policy Opposition(4 items),Personal Responsibility(4 items)and Financial Discrimination(3 items).Multiple aspects of cancer stigma can be assessed by this multidimensional scale.All attitude items are based on a 6-point scale(‘disagree strongly’to ‘agree strongly’or ‘definitely not’to ‘yes de fi nitely’)and reversely scored as needed.All subscales have good construct validity,internal and test-retest reliability,and fi t well with the stigma-related literatures.This scale can be used in studies that assess PHS among patients with different types of cancer,including breast cancer.In another area of Marlow's research,which used the CASS to explore PHS between six different cancer types(lung,breast,colorectal,skin and cervical),this scale also showed good reliability and validity.26

4.3.Body Image after Breast Cancer Questionnaire(BIBCQ)-body stigma subscale

The BIBCQ is a multidimensional assessment of the long-term specific impact of breast cancer on body image.27It is a selfreport scale comprising 53 items,regardless of surgery type.Higher scores ref l ect greater body image disturbance.The BIBCQ is made up of six subscales(Vulnerability,Body Stigma,Limitations,Body Concerns,Transparency and Arm Concerns)for which good reliability was found(ranging from 0.77 to 0.87).The Body Stigma subscale comprises items associated with bodyshame and avoidant behaviors(e.g.,“I try to hide my body”).The diagnosis and treatment of breast cancer have a profound impact on body image,and many patients have intense feelings of body stigma.For breast cancer patients,the intensity of the feeling of being ashamed of body image can be assessed by means of the Body Stigma subscale of BIBCQ.28

5.Predictors for PHS

Marlow and Wardle found that PHS of cancer patients was influenced by certain socio-demographic factors.25Being male was found to be a predictor for more intense PHS,as was younger age.White British patients who were from an ethnic group had stronger PHS.Patients who were more educated were more inclined to experience higher PHS,while those who had at some time been around a person with cancer(whose family member or close friend has had cancer)or scored higher on social desirability(caring more strongly about what others think of them)were more likely to report lower PHS.Younger age predicted greater PHS,a similar fi nding con fi rmed by a multi-center study conducted in women who carried a BRCA1 or BRCA2-mutation.9Lebel and Devins showed that personal behavior that increases cancer risk induces PHS.29That is,‘lifestyle’causes could in fl uence PHS.

According to the related research fi ndings,clinical factors are also predictors for PHS of cancer patients.Side effects of treatment are associated with PHS of cancer patients.For most breast cancer patients who had experienced chemotherapy,PHS was driven partly by chemotherapy-induced alopecia12That is,breast cancer patients who experienced chemotherapy and relevant alopecia had stronger PHS than those without chemotherapy or alopecia.Vodermaier et al9reported that some female carriers of a BRCA1/2-mutation might experience PHS as a consequence of body dis fi gurement.More speci fi cally,BRCA1/2-mutation carriers who have undergone prophylactic mastectomy experience stronger PHS in relation to women without this surgery,because prophylactic mastectomy has negative impacts on body image and sexuality.

6.Effects of PHS on patients with breast cancer

In other stigmatized diseases,such as mentalillness and human immunodeficiency virus/acquired immunodeficiency syndrome(HIV/AIDS),PHS has been shown to negatively affect patients and their health outcomes.Several studies about PHS of cancer suggest similar effects on patients with breast cancer.Stigma-related sentiments are commonly expressed by breast cancer survivors,for example,how their body ‘failed them’or how they feel‘broken’or‘disf i gured’.

Treatments,their associated side effects,and the traumatic nature of the breast cancer experience frequently elicit intense PHS and the resulting considerable disruptions in sexual functioning.30Boquiren et al.'s study28indicated that body stigma had significant correlations with sexual functioning(the ‘sexually engaged’group reported significantly less body stigma than the‘not sexually engaged’group).Breast cancer survivors who reported significant body image concerns post-treatment may represent a vulnerable subgroup developing sexual dysfunction.

A substantial body of evidence has suggested that the PHS has a deleterious impact on breast cancer patients'attitudes,behaviors,psychosocial and quality of life outcomes.Almost all of the breast cancer patients suffered from strong adverse effects from the treatmentsadministered.Thevisiblechangesmostpatients encountered from long-term treatment occurred alongside feelings of sickness,interference with sleeping patterns,and changed lifestyles,which reduced their quality of life.6A qualitative study conducted in women with breast cancer showed that the PHS not only delays women from engaging in care early but also hinders women from remaining engaged with care through to treatment completion.7Cho et al,31who conducted a study examining the association between PHS and depression among cancer survivors,claimed that cancer patients who had or experienced PHS were 2.5 times more inclined to have depression than those with positive attitudes.Similarly,in women carrying a BRCA1/2-mutation,Vodermaier et al9found that BRCA1/2-mutation carriers high in feelings of PHS experienced more cancer-specific distress.Moreover,they also drew the conclusion that the PHS was associated with more intrusive and avoidant thoughts in female BRCA1/2-mutation carriers.9In summary,for breast cancer patients,with increasing sense of PHS there might be more depression,poorer sleep quality,a decreased tendency to seek healthcare,and a decrease in quality of life.

7.Interventions of PHS

Efforts to alleviate the PHS have focused on helping individuals acknowledge and adjust to life with treatable but incurable diseases,and development of social and health policies for minimizing the PHS must be taken into consideration,because the PHS extensively exists in and has deleterious effects on the patients.Interventions may focus on support for affected individuals,changing prejudice and behavior of people who stigmatize in the general population,and eliminating or controlling the stigmatized condition.20Interventions for the general public try to rectify the misapprehensions and unfounded fears about the risks of people with stigmatized conditions.Interventions also aim to enhance empathy with affected people by emphasizing the fact that health status is not the only feature of the identity of an individual with a stigmatized condition.Weiss et al19clearly noted that health and social policies for minimizing PHS include access to care,health fi nancing,and research support.

Interventions targeting PHS of breast cancer patients could be found through several related studies.Mutebi and Edge declared that breast cancer awareness that aims to encourage women to be more aware of their breasts could contribute towards reducing the PHS of the diagnosis and increasing earlier presentation.8Ginsburg et al32showed a bene fi cial phenomenon that community healthcare workers shared testimonials of the successfully treated patients with the general public,which helped to decrease the PHS of breast cancer.Najmabadi et al33opined that self-disclosure of breast cancer diagnosis is very necessary for patients because talking about cancer diagnosis helps people to re-evaluate their perceptions and make sense of their experiences.In a manner of speaking,self-disclosure appears to play an important role in patients'health outcomes.Meanwhile,they also found that after women self-disclosed freely to family,friends and colleagues,the PHS of breast cancer was far less than it once was.33Meacham et al7noted that key factors to overcoming the PHS and engaging in care included acceptance of disease diagnosis,strong social support and relevant knowledge of breast cancer.Thus,encouraging patients to accept the diagnosis of breast cancer,providing patients with powerful social support and helping them to acquire more knowledge of breast cancer may be effective measures to overcome the PHS.Meacham et al also concluded that interventions aimed at reducing fear of breast cancer could help to reduce the PHS and promote cancer care engagement.7

8.Discussion

PHS refers to the attachment of negative connotations to some types of disease diagnoses.16The PHS negatively impacts the health and well-being of patients,the ability and willingness of patients to access health care,the patient-provider relationship and the supply of care.The PHS has been extensively studied in many disorders and diseases,and PHS of cancer prevalent in the world today has drawn increasing public health concern.Cancer is no longer simply a part of their lives;for cancer patients,it becomes the main element of their everyday lives and identities.Patients describe their experiences of cancer in terms of “depression”, “psychic distress”and “emotionalinstability”.This feeling is mainly related to the cancer treatment,and in particular to chemotherapy,which is seen as being extremely invasive,attacking the body more than healing it.12

Almost all of breast cancer patients had to face asymmetrical breasts,which surgery left the patients with,and endure various adverse effects resulting from their treatment,including nausea,vomiting,fatigue,hair loss,and lack of appetite.So they may experience mistrust in their body and changes in their perception of themselves,and even feel different,isolated or alienated from others due to all these changes and effects.The changes in body appearance and the adverse effects have great impacts on the daily activities and the life quality of breast cancer patients.The adverse effects of the treatment also lessen patients'capacity for being independent and interfere with their normal lifestyles.Most breast cancer patients feel ashamed by the changes in their body image and seek to find ways to conceal their imperfect bodies,because breasts are seen as a symbol of gender identity and femininity of women.6

Studies conducted in different countries have indicated that breast cancer patients experience different levels of PHS after receiving various types of treatments,i.e.,people living with breast cancer continue to endure PHS and discrimination in the context of health care.4,6-13PHS is common among patients with breast cancer and is associated with negative attitudes and passive avoidance behaviorssuch asdecreased healthcare seeking behavior.SIS and CASS have been applied to measure the PHS of cancer patients,including breast cancer patients.Whether the validityand reliability of the above scales are desired when theyare used to assess the PHS of breast cancer,more studies for further verification are needed.Although the Body Stigma subscale of BIBCQ is used to examine the body stigma of breast cancer patients,developing more instruments that are specialized for measuring PHS of breast cancer patients is necessary.Based on a large number of research results,PHS regarding cancer is influenced by many socio-demographic,clinicaland psychologicalfactors.Future studies should continue to examine the relationship between PHS and these predictors,explore whether there are other predictors,and discuss effective interventions of PHS on the basis of the predictors.

According to previous studies,the PHS has debilitating effects on breast cancer patients and their health outcomes,including sexual dysfunction,depression,poor sleep quality,decreased tendency to seek healthcare and decrease in quality of life.Many interventions have been found effective for mitigating or eliminating the PHS of patients with specific diseases such as mentalillness,HIV/AIDS and cancer,but more interventions that are valid,particularly for patients with breast cancer,are still needed.

9.Conclusions

In conclusion,previous studies have shown that breast cancer is a highly stigmatized disease,with almost all breast cancer survivors experiencing different levels of PHS,and the PHS may lead to adverse health behaviors.Healthcare providers need to be aware of PHS and its potentialimpact on patients'interaction with the medical system and should consider speci fi cally addressing PHS when discussing the disease and treatment course.All the relevant fi ndings might also re fl ect a bias against breast cancer among the general public,which could prevent breast cancer patients from seeking social support and make it dif fi cult to conduct research among such patients.To improve the status,developing more effective interventions aimed at preventing negative effects of PHS in this population has become an emergent and signi fi cant task.

Conf licts of interest

All contributing authors declare no conf licts of interest.

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11 June 2017

in revised form

15 August 2017

https://doi.org/10.1016/j.cnre.2017.10.002

2095-7718/©2017 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).*

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E-mail address:caiyunzhang@aliyun.com(C.-Y.Zhang).

Peer review under responsibility of Shanxi Medical Periodical Press.aQian-Xin Wang and Yan Bai contributed equally to this work.

How to cite this article:Wang Q-X,Bai Y,Lu G-F,et al.Perceived health-related stigma among patients with breast cancer.Chin Nurs Res. 2017;4:158-161. https://doi.org/10.1016/j.cnre.2017.10.002